Tuesday, April 1, 2014

DIAGNOSTIC DIFFERENTIATION OF DIGESTIVE SYMPTOMS

In this blog post, I will discuss the diagnostic differentiation between various digestive symptoms and specifically, a feeling of distension, fullness, oppression and stuffiness.

A feeling of  DISTENSION (zhang 胀) indicates stagnation of Qi.  This type of sensation will be seldom referred to as "distension" by Western patients: more often than not, patients will call it a feeling of “bloating”, "bursting", "being blown-up", etc.

A feeling of distension is both subjective and objective.  Subjectively, the patient feels bloated, and objectively, it can be seen and palpated.  On palpation it feels like an over-inflated balloon, it resists on palpation and “rebounds”.

A feeling of distension indicates Qi stagnation: it is the cardinal symptom of Qi stagnation which usually affects the Liver.  Remember, however, that it affects also other organs: in the context of digestive disorders, it affects the Stomach, Intestines and Spleen.

Note that Qi stagnation does not always derive from anger (whether repressed or not) but it frequently derives from worry or guilt.

The pulse reflects where the stagnation is centered. We can distinguish Liver-Qi stagnation, Stomach-Qi stagnation, Spleen-Qi stagnation and Qi stagnation in the Intestines.

- Liver-Qi stagnation: abdominal and/or epigastric bloating, related to emotional state. Pulse all Wiry or Wiry on left.


- Stomach-Qi stagnation: epigastric bloating, not much related to emotional state.  Alleviated by burping. Pulse Wiry on right Guan.


- Spleen-Qi stagnation: lower abdominal bloating, loose stools. Alleviated by passing gas and by rest. Pulse slightly Wiry on left and Weak on right.


- Intestines Qi stagnation: abdominal distension and pain,  borborygmi, constipation.  Alleviated by passing gas. Pulse Wiry on both Chi position.


Distension of epigastrium: Ren-10 Xiawan, Ren-12 Zhongwan, ST-21 Liangmen, ST-34 Liangqiu, ST-40 Fenglong, GB-34 Yanglingquan.

Distension of lower abdomen: ST-25 Tianshu, SP-15 Daheng, GB-34 Yanglingquan, Ren-6 Qihai.

A feeling of FULLNESS (man 满 ) indicates retention of food or Dampness. A feeling of fullness is different than a feeling of distension.  One  literally feels full and slightly nauseous.   It may affect the epigastriun or abdomen.

The feeling of fullness is subjective and objective.  Subjectively, the patient feels full and slightly nauseous.  It is felt objectively on palpation but not seen on observation. On palpation, the abdomen feels hard but not elastic as in the feeling of distension.

Epigastric fullness: ST-19 Burong, ST-21 Liangmen, Ren-10 Xiawan, SP-4 Gongsun/P-6 Neiguan (Chong Mai), ST-34 Liangqiu.

Abdominal fullness: ST-25 Tianshu, ST-27 Daju, SP-4 Gongsun/P-6 Neiguan (Chong Mai),  ST-37 Shangjuxu, ST-39 Xiajuxu.

A feeling of OPPRESSION (men 闷 ) denotes Phlegm or severe Qi stagnation.

A feeling of oppression is purely subjective and it is experienced mostly in the chest.  Some patients would describe it as a “weight” on the chest.  A feeling of oppression indicates Phlegm or also more severe stagnation of Qi.  The translation of this term cannot adequately convey the image evoked by its Chinese character: this depicts a heart constrained by a door and, besides the physical sensation, it also implies a certain mental anguish associated with this feeling.

In Western patients too, a feeling of oppression of the chest reflects emotional stress especially to do with sadness, grief, worry, shame and guilt.

Feeling of oppression of the chest: Ren-17 Shanzhong, P-6 Neiguan, LU-7 Lieque, ST-40 Fenglong.

A feeling of STUFFINESS (pi  痞) indicates Stomach-Qi deficiency or Stomach-Heat.  Contrary to the previous two sensations which can be felt objectively on palpation (e.g. a distended or full abdomen feels so on touch), the sensation of stuffiness is only subjective and the abdomen feels soft on touch.

The feeling of stuffiness is usually in the epigastrium.






DISTENSION
FULLNESS
OPPRESSION
STUFFINESS
Chinese
Zhang
Man 滿
Men 
Pi 
Subjective/objective
Both
Both
Subjective
Both
Objective on what
Palpation and observation
Palpation

Palpation
Symptom
Bloating
Feeling full, nausea
Feeling of weight
Mildly full
Pattern
Qi stagnation
Dampness
Phlegm
Deficiency and Stomach-Heat


Sunday, February 23, 2014

COSMOLOGICAL SEQUENCE OF THE 5 ELEMENTS - PART 3

In the first Clinical Tip we discussed the possible origin of the theory of the 5 Elements and the connection between the ancient Four Directions and the Cosmological arrangement of the 5 Elements (with Earth in the Centre).  In the second Clinical Tip we discussed the clinical application of the Cosmological Sequence of the 5 Elements.

In this third and last Clinical Tip I would like to address the relationship between the 5 Elements and the 4 Seasons. Numerology pervades Chinese medicine very often with contradictions.

There is the number 1 which is the Dao, bearing in mind that the Dao is part not only of Daoist philosophy but also of the philosophies of Confucianism and of the Yin-Yang School.

There is the number 2 which is of course Yin and Yang.  Number 3 is Heaven-Earth-Person (Tian-Di-Ren). I deliberately use the word “person” rather than “man” as ren in Chinese does indeed mean “person”: nan ren is a male person and nu ren a female one.

Incidentally, the “Earth” of “Heaven, Earth and Person” is not the same as the “Earth” of the 5 Elements. The “Earth” of “Heaven, Earth and Person” is the counterpole of Heaven: Heaven refers to a state of dispersal of Qi and Earth to a state of condensation of Qi. The “Earth” of the 5 Elements is a “neutral” centre of the other four Elements.



Number 4 corresponds corresponds to the Four Seasons.  Number 5 is of course the 5 Elements.

Thus, these are the correspondences:
1 = Dao
2 = Yin-Yang
3 = Heaven, Earth, Person
4 = Four Seasons
5 = 5 Elements

I mentioned contradictions earlier because the correspondence between these numbers and the phenomena they represent is not always smooth and the 4 Seasons and 5 Elements are a good example of this. How do we fit 5 into 4?  Another very good example is the conundrum of 12 channels but “5 Zang and 6 Fu”.

So, how are four seasons reconciled with 5 Elements?  They are reconciled because Earth does not correspond to any season, as it is the centre, the neutral term of reference around which the seasons and the other Elements spin.

The “Classic of Categories” (Lei Jing, 1624) by Zhang Jie Bin has a very interesting statement: “The Spleen belongs to Earth which pertains to the Centre, its influence manifests for 18 days at the end of each of the four seasons and it does not pertain to any season on its own”.



This confirms that the Spleen does not correspond to any season and that its influence manifests for 18 days at the end of each season.  Again, it is better to refer to the Cosmological arrangements of the 5 Elements rather than the Generating (Sheng) sequence. In the Cosmological arrangement, the Spleen is in the centre and does not correspond to any season.



In the Generating sequence, the Earth has moved out between Fire and Metal and, as it comes after Fire (Summer), it “must” correspond to “Late Summer”.  The association between Earth and Late Summer has never convinced me.  What the Lei Jing says about the energy of the Spleen influencing the end of every season is more convincing.  The Earth provides nourishment, and it make sense that the Spleen should influence the end of every season.



The same idea is also in the “Discussion of Prescriptions from the Golden Chest” (Jin Gui Yao Lue, c. AD 220) by Zhang Zhong Jing: “During the last period of each season, the Spleen is strong enough to resist pathogenic factors”.

Thus, in the cycle of seasons, the Earth actually corresponds to the late stage of each season. Although the Earth element is often associated with “Late Summer” or “Indian Summer”, it also corresponds to “Late Winter”, “Late Spring” and “Late Autumn”.

Clinically, the position of the Earth in the centre makes sense as the Earth is the origin of nourishment and the Stomach and Spleen are the source of Post-Natal Qi. Nourishing the Earth and tonifying the Stomach and Spleen will tonify all other organs.

The association of the Spleen with the end phase of each season also has some clinical relevance as Qi and Blood tend to decline at the end of each season (especially autumn and winter) and it therefore makes sense to tonify Stomach and Spleen then.

To tonify Stomach and Spleen, I use ST-36 Zusanli and SP-6 Sanyinjiao, often with moxa on the needle.  If they are particularly deficient, I add direct moxa cones on BL-20 Pishu and BL-21 Weishu.  

1.  1982 Classic of Categories (Lei Jing), People’s Health Publishing House, Beijing, p 46 (first published 1624).
2.  1981 Discussion of Prescriptions of the Golden Chest (Jin Gui Yao Lue Fang Lun), Zhejiang Scientific Publishing House, p 1 (first published c. AD 220).

Friday, January 31, 2014

COSMOLOGICAL SEQUENCE OF THE 5 ELEMENTS - PART 2

In the previous Clinical Tip I discussed the clinical application of the Cosmological sequence of the 5 Elements, i.e. the one placing the 5 Elements in the form of a cross.  I concentrated on the “vertical” relationship between Fire and Water and between Heart and Kidneys. 



In this Clinical Tip, I will discuss the clinical significance of the Earth being in the Centre and of Wood and Metal being on left and right respectively.

EARTH IN THE CENTRE
The placing of the Earth in the Centre of the Cosmological sequence of the 5 Elements is crucial.  The Earth is in the Centre in a cosmological  and a clinical sense.  The four Elements of Fire, Water, Wood and Metal are placed along a square with Fire at the top (South), Water at the bottom (North), Wood on the left (East) and Metal on the right (West).  The square has a centre that is the point of reference which pertains to Earth.  There can only be a “top”, “bottom”, “left” and “right” in reference to a centre.


The placing of the Earth in the centre is completely lost in the Sheng cycle of the 5 Elements where Earth is in between Fire and Metal.  As we saw in the previous Clinical Tip, the Sheng and Ke cycle (introduced by Zou Yan) has a strong political significance.

From a clinical perspective, placing the Earth in the centre has many applications.  First of all, the Spleen is the origin of Post-natal Qi and Blood and, as such, it nourishes all the other organs.  It therefore make sense for Earth to be in the centre.

From the point of view of Qi movement, Stomach and Spleen are in the centre in another sense and that is being in the Middle Burner between the Upper Burner above and the Lower Burner below.  Every organ’s Qi has a certain direction of movement.  For example, Heart-Qi and Lung-Qi descend and Kidney-Qi descends. The Stomach and Spleen are in the middle and their Qi movement influences all other Qi movements.  Stomach-Qi descends and Spleen-Qi ascends: all the other organs depend partially on these two movements of Stomach-Qi and Spleen-Qi. If Qi movement is disrupted in the middle, it will affect the upper and lower Burners.



From a clinical perspective, tonifying the Stomach and Spleen tonifies the Centre and therefore all the other organs too.  To do this, I use ST-36 Zusanli and SP-6 Sanyinjiao usually with moxa on the needle. This is a very simple and extremely effective treatment that tonifies Stomach and Spleen and Qi and Blood of all organs.

WOOD ON THE LEFT, METAL ON THE RIGHT
The following is an article from the Journal of Chinese Medicine  (Zhong Yi Za Zhi) from Beijing. Before reading this article, I should explain the meaning of “Qi Mechanism” [Qi Ji ].  The Qi Mechanism is a term that includes the ascending-descending and entering-exiting of Qi.  In every organ and every part of the body, Qi ascends or descends: this is an essential aspect of the physiology of every organ.  For example, in the Middle Burner, Stomach-Qi descends and Spleen-Qi ascends.

Apart from the ascending-descending of Qi, physiology also includes the entering-exiting of Qi.  This is a less well-known aspect of the Qi movement.  The ascending-descending of Qi represents a “vertical” movement of Qi while the entering-exiting represents a “horizontal” movement of Qi.  For example, in the Cou Li space (the superficial space between the skin and muscles where Wei Qi circulates), Qi goes in and out: this is an aspect of the entering-exiting of Qi.
   
The “Su Wen” in chapter 68 says: “Without exiting-entering of Qi, there would be no birth, growth, maturity and decline. Without ascending-descending, there would be no birth, growth, transformation, receiving and storage. All organs rely on the ascending-descending and exiting-entering of Qi”.










The entering and exiting of Qi plays an important role in the transformation, transportation and excretion of fluids.



In Liver diseases do not forget to treat the Lungs
Journal of Chinese Medicine (Zhong Yi Za Zhi) 1998, 2, p. 73
The Lungs govern Qi and Qi regulates the functions of the Zangfu.  The Lungs have the function of jie zhi  which means to control, to check, to moderate.  This means that the Lungs “restrict” and regulate the functions of all the Zangfu.  Lung-Qi descends and communicates with Kidney-Water.  The  Lung  function of “restricting”, regulating and adjusting the functions of all the Zangfu is dependant on the descending of Lung-Qi.

Ascending and descending of Qi
Liver-Qi normally ascends and this makes the Qi mechanism work smoothly, so that Qi and Blood are harmonized and flow freely.  There is a saying that states: “The ascending of Qi stems from the Liver” (Lin Pei Qin).  The Lungs is a so-called “tender” organ, it governs Qi and its Qi descends.  If Lung-Qi does not descend there is a situation of rebellious-Qi causing cough.

Ye Tian Shi said: “The Liver is on the left and its Qi rises, the Lung is on the right and its Qi descends.”  He also said: “The Qi Mechanism of our body is mirrored on Heaven and Earth in nature, the Liver is on the left and its Qi rises, the Lung is on the right and its Qi descends.  When Lung-Qi does not descend, Liver-Qi rebels horizontally.”  Therefore, the ascending of Liver-Qi and descending of Lung-Qi are essential for the correct functioning of the ascending and descending of Qi in the Qi Mechanism.  Moreover, the ascending and descending of Qi regulates the smooth flow of the Qi mechanism. [Please note that this a physiological ascending of Liver-Qi, not Liver-Yang rising.]


In pathological conditions, when Liver-Qi rises too much it impairs the descending of Lung-Qi and therefore it leads to the situation of “Left ascending too much and right not descending enough.”  This leads to cough, headache, red eyes, spitting of blood, epistaxis etc.  If Liver-Qi stagnates and does not rise enough, Lung-Qi also stagnates and this leads to breathlessness and a feeling of oppression of the chest, constipation, urinary retention, etc. 

Conversely, Lung pathologies can affect the Liver, such as when Lung-Qi does not descend properly, this could lead to Heat which impairs the free-flow of Liver-Qi.  This leads to cough, hypochondrial and chest pain and distension and fullness, dizziness, headache etc.  Therefore the reciprocal control and regulation between the Liver and Lungs is essential for the smooth function of the Qi Mechanism.  The descending and diffusing of Lung-Qi has controlling, regulating and adjusting actions on the rising of Liver-Qi, which reflects also the 5-Element control of Wood by Metal.

Clinical application
In many Liver-Qi pathologies, it is necessary to regulate and treat Lung-Qi by strengthening the diffusing and descending of Lung-Qi.  This has two effects: on the one hand it controls Heat by restoring the normal ascending and descending and, on the other hand, it frees the passages of the Triple Burner so that Water and Dampness are transformed and Liver can store Blood.

Descending of Lung-Qi subdues rebellious Liver-Qi

In conditions of emotional stress leading to Qi stagnation, Liver-Qi loses its free flow, the channel Qi does not flow smoothly and this can rise upwards to harass Heart and Lungs.  Stagnant Qi turns into Heat which rises, Lung-Qi fails to descend and this leads to cough, breathlessness, chest pain, dizziness, headache etc.  Hence the saying, “in Liver-pathology do not forget to treat the Lungs.” 

Herbs that make Lung-Qi descend include Xing Ren, Chuan Bei Mu, Xuan Fu Hua, Su Zi, Hai Ge Ke, etc.  When Qi rebels upwards with Heat, use herbs such as Huang Qin, Sang Bai Pi, Qian Hu, Ma Dou Ling, etc.  When Fire rises upwards in chronic situations and the Lungs suffer from dryness, use Sha Shen, Mai Men Dong, Shi Hu, Pi Pa Ye etc.  When Lung-Qi fails to descend and Liver-Qi ascends too much, the formula Xie Bai San, with the addition of cooling Blood and clearing Liver-Heat herbs, can restore the normal flow of Qi (using a high dose of Sang Bai Pi).

Regulate the Qi Mechanism in order to relieve stagnation of Liver-Qi

In conditions of stagnation of Liver-Qi from emotional problems, besides using herbs which move Qi and eliminate stagnation, one must also pay attention to making Lung-Qi descend.  This will keep in check the ascending of Qi, regulate the Qi mechanism and promote the smooth flow of Qi in the Triple Burner.

Herbs to do this include Pi Pa Ye, Xing Ren, Chuan Bei Mu, Zi Wan.  At the same time, use herbs which promote the diffusing of Lung-Qi, such as Ma Huang, Jie Geng, Gua Luo Pi, etc.  When stagnation of Lung-Qi has given rise to Phlegm, one must clear the Upper Burner and treat Lung-Qi with herbs such as Pi Pa Ye, Xing Ren, Gua Luo Pi, Yu Jin, Ban Xia, Fu Ling, Sheng Jiang, Zhu Li, etc.